VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Riverside Assisted Living at Smithfield
101 John Rolfe Drive
Smithfield, VA 23430
(757) 357-3282

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: March 9, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Technical Assistance:

Work schedule and posting-- name of current on-site person in charge Emergency preparedness-- emergency food/water supply

Comments:

An unannounced mandated monitoring inspection was conducted on 3/9/22 and 3/10/22 by two Licensing Inspectors. Information gathered during the inspection determined non-compliance with applicable standards or law, the violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1070-B
Description:	Based on observation, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident with a serious cognitive impairment, these materials or objects shall be in accessible to the resident except under staff supervision. Evidence: 1. During a tour of the facility on 3/09/22, Licensing Inspectors (LI) observed a spray bottle of surface sanitizer under an unlocked cabinet, two food thermometers with sharp tips and a wine bottle opener in an unlocked drawer in the secured unit. 2. Staff #1 acknowledged the surface sanitizer, two food thermometers and wine bottle opener should not be unlocked and removed the items from the unit.
Plan of Correction:	Please contact the licensing inspector for more information.
Standard #:	22VAC40-73-310-D
Description:	Based on documentation review and interview, the facility failed to provide written assurance to the resident or legal representative that the facility has the appropriate license to meet his care needs at the time of admission, this document shall be signed and kept in the resident?s record. Evidence: 1. Resident #1, Resident #2 and Resident #5 did not have a copy of the signed written assurances in their records. 2. Staff #3 acknowledged the aforementioned residents did not have a signed written assurances in the record at the time of inspection.
Plan of Correction:	Please contact licensing inspector for more information.
Standard #:	22VAC40-73-430-H-2
Description:	Based on documentation review and interview, the facility failed to ensure that copy of a written discharge statement was retained in resident records. Evidence: 1. The record for resident #7 did not include a discharge statement. 2. The record for resident #8 did not include a completed discharge statement. The statement did not contain a discharge date, or administrator signature and date. Additionally, were no actions documented to listed the assistance the facility provided to the resident during the discharge/ relocation process. 3. Staff #3 acknowledged the discharge statement was not in resident #7?s record and the discharge statement in resident #8?s record was incomplete.
Plan of Correction:	Please contact the licensing inspector for more information.
Standard #:	22VAC40-73-450-D
Description:	Based on documentation review and interview, the facility failed to ensure when hospice care is provided to a resident the services by each shall be included on the Individualized Service Plan (ISP). Evidence: 1. Resident #2?s ISP dated 4/27/21 did not list the hospice care and the agreed upon coordinated plan of care for the resident.
Plan of Correction:	Please contact the licensing inspector for more information.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review, the facility failed to have the Individualized Service Plan (ISP) signed by the resident or his legal representative. Evidence: 1. The following resident ISPs did not have a resident or legal representative signature: Resident #3 (ISP dated 11/6/2019), Resident #4 (ISP dated 7/9/2021), and Resident #5 (ISP dated 4/6/2021).
Plan of Correction:	Please contact the licensing inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to review and update Individual Service Plans (ISP) at least once every 12 months. Evidence: 1. Resident #3's ISP was last updated on 11/6/2019.
Plan of Correction:	Please contact the licensing inspector for more information.
Standard #:	22VAC40-73-550-G
Description:	Based on record review, the facility failed to ensure the review of resident rights and responsibilities were reviewed annually. Evidence: 1. Resident #6's last documented review of rights and responsibilities was dated 12/16/2020.
Plan of Correction:	Please contact the licensing inspector for more information.
Standard #:	22VAC40-73-580-C
Description:	Based on observation and interview the facility failed to ensure personnel was available to help any resident who may need assistance when eating. Evidence: 1. On 3/9/22, during the inspection of the facility, Licensing Inspectors were in the main dining room while 7 residents were eating lunch. There were no staff members present. 2. On 3/10/22, during the inspection of the memory care unit, 3 residents were eating breakfast and there were no staff members present.
Plan of Correction:	Please contact the licensing inspector for more information.
Standard #:	22VAC40-73-680-I
Description:	Based on documentation review, the facility failed to include all required documentation on the Medication Administration Record (MAR). Evidence: 1. Resident #1 has a physician's order for Insulin Toujeo Solo Inj 300U/ML 35 units subcutaneously one time a day. The medication administration space for 3/5/22 was blank and there was no information documented on the back of the MAR. 2. Resident #9 has a physician's order for Tylenol 325mg PRN 2 tablets by mouth every 6 hours as needed. A review of the March 2022 MAR, indicated the medication was administered however, the required documentation of effectiveness of the Tylenol was not documented for 3/3/22, 3/5/22, 3/6/22, or 3/7/22. 3. The master list of staff members who administer medications did not contain the name, signature and initials of all staff member who administer medication.
Plan of Correction:	Please contact the licensing inspector for more information.
Standard #:	22VAC40-73-720-A
Description:	Based on record review, the facility failed to ensure Do Not Resuscitate (DNR) order was included on the Individualized Service Plan (ISP). Evidence: 1. Resident #2 and Resident #5 have a DNR order; however it is not documented on the residents' ISPs.
Plan of Correction:	Please contact the licensing inspector for more information.
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview, the facility failed to maintain the interior and exterior of the building in good repair and keep it clean and free of rubbish. Evidence: During a tour of the safe and secure unit of the facility, LIs observed: 1. There were 2 discolored ceiling tiles in hallway with dark stairs outside room# 14. 2. There were items to be discarded in the hallway near the nurse?s station to include 2 rollator walkers, 4 leg rests for wheel chairs, a walker and a bed box spring. 3. Staff #2 acknowledged that the aforementioned items were to be discarded.
Plan of Correction:	Please contact the licensing inspector for more information.
Standard #:	22VAC40-73-890-D
Description:	Based on observation, the facility failed to replace florescent lights when they flickered. Evidence: 1. During an on-site inspection of the secured unit on 3/9/22, the ceiling hallway light outside room #13 was flickering. 2. Staff #1 acknowledged the light was flickering and need to be replaced.
Plan of Correction:	Please contact the licensing inspector for more information.